Blood Pressure Measurement Guidelines

for Physical Therapists

Ethel M. Frese, PT, DPT, MHS, CCS;1 Ann Fick, PT, DPT, MS, CCS;2
H. Steven Sadowsky, PT, RRT, MS, CCS3

1
Department of Physical Therapy and Athletic Training, Saint Louis University, St. Louis, MO
2
Department of Physical Therapy, Maryville University, St. Louis, MO
3
Department of Physical Therapy and Movement Science, Northwestern University, Chicago, IL

ABSTRACT Blood Pressure (JNC 7) provides a scheme for classifying

Vital sign measurement and assessment are important com-
ponents of the review of systems in a physical therapy ex-
amination for individuals with and without documented
cardiopulmonary disease. The measurement of blood pres-
sure gives the therapist information regarding the patient’s
baseline cardiovascular status, response to exercise/activity,
and guides exercise prescription. Accurate measurement
of blood pressure is critical for making appropriate clinical
decisions especially if physical therapists wish to play an
important role as primary health care providers. The pur-
pose of this paper is to present recommended guidelines
for blood pressure measurement by physical therapists and
physical therapist assistants.
Key Words: blood pressure measurement, vital sign assess-
ment, guidelines
BLOOD PRESSURE MEASUREMENT GUIDELINES FOR
PHYSICAL THERAPISTS
As stated in the Guide to Physical Therapist Practice,
assessment and monitoring of vital signs are important
components of the review of systems in a physical therapy
examination for individuals with and without documented
cardiopulmonary disease.1 The U.S. Preventive Services
Task Force recommends screening for high blood pres-
sure in adults 18 years of age and older.2 Blood pressure
screening should occur every two years in people with
blood pressures less than 120/80 mm Hg, and every year
for people with systolic blood pressure 120 mm Hg to 139
mm Hg, or diastolic blood pressure 80 mm Hg to 89 mm
Hg. The measurement of blood pressure gives the therapist
information regarding the patient’s baseline cardiovascular
status, response to exercise/activity, and guides exercise
prescription.
The 7th Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Address correspondence to: Ethel M. Frese, PT, DPT,
MHS, CCS, Department of Physical Therapy and Ath-
letic Training, Saint Louis University, 3437 Caroline
Street, St. Louis, MO 63104 (freseem@slu.edu).
blood pressure for adults (≥ 18 years of age) and defines hy-
pertension as beginning at systolic and diastolic pressures
of 140/90 mm Hg, respectively.3 Table 1 presents the JNC
7 classification of hypertension, which is based on an aver-
age of at least two seated blood pressure measurements,
properly measured with well-maintained equipment in a
single visit. In order for the diagnosis of hypertension to
be established, an elevated blood pressure measurement
must occur in at least two separate visits to the health care
provider’s clinic or office.3
Table 1. Classification of Hypertension3,4
Classification Systolic Blood Diastolic Blood
Pressure (mm Hg) Pressure (mm Hg)
Normal <120 <80
Prehypertension 120–139 80–89
Stage 1 140–159 90–99
hypertension
Stage 2 ≥160 ≥100
hypertension
Modified from Chobanian et al3 Pickering et al4
Hypertension is the most common primary diagnosis
in the United States. It is a major risk factor for coronary
heart disease, stroke, and renal failure, and affects 29% of
the adult US population.3,4 Twenty-two percent of persons
who have hypertension are unaware that they have it.3 In
addition, one-fourth of the population 20 years and older
is estimated to be prehypertensive, which is defined as a
systolic blood pressure of 120-139 mm Hg, and/or a dia-
stolic blood pressure of 80-89 mm Hg. Prehypertension
contributes to about 15% of blood pressure related deaths
for coronary artery disease.4 Pulse pressure (systolic blood
pressure minus diastolic blood pressure), which is normally
around 40 mm Hg, has been postulated to be a better pre-
dictor of cardiovascular risk than mean arterial pressure.5,6
Elevated pulse pressures (> 60 mm Hg) are associated with
higher cardiovascular morbidity and mortality rates among
all arterial blood pressure data.5,6
Hypertension and prehypertension in children and ado-
lescents 8 to 17 years old have increased since 1999, and
both are frequently undiagnosed in children 3 to 18 years
of age.5,13 Childhood blood pressure is a strong predictor

Vol 22 v No 2 v June 2011 Cardiopulmonary Physical Therapy Journal 5

of blood pressure levels in adulthood, and hypertension Table 2. Most Common Sources of Error in Blood Pressure
and prehypertension are a significant health issue in the Measurement Technique4,11
young, especially with the prevalence of childhood obesi- • Cuff size and application
ty.7,8 Therefore it is very important for both young and older • Arm position
individuals with hypertension and prehypertension to be • Differences in arm size
identified and treated.7,9,10 • Rest period prior to measurement
• Inflation/deflation method
Accurate measurement of blood pressure is critical for • Concentration of the measurer
making appropriate clinical decisions in management of • Digit bias (tendency to record a zero as the last digit)
high blood pressure to reduce cardiovascular risk and pre- • Lack of repeated measures
vent target organ damage. An inaccurate measurement of • Time between repeated measures
blood pressure could lead to a patient being falsely clas- • Lack of calibration/maintenance of measurement devices
• Body position
sified as hypertensive or falsely classified as having high • Muscle tension
normal or normal blood pressure as well as lead to faulty • Quality of stethoscope
clinical decisions regarding patient progression in an exer- • Level of training of measurer
cise program.11,12
Error can be minimized when a standard measure-
ment protocol and a standard training protocol are used.13 ment error is greater with an undersized cuff than it is with
However, health care providers frequently do not comply an oversized cuff. Table 3 presents recommendations for
with established guidelines for measuring blood pressure ideal cuff sizes to be used clinically.
and guidelines are not always consistent with each other.14
To our knowledge there are no published guidelines for MEASUREMENT FOR BASELINE/DIAGNOSTIC
blood pressure measurement with an emphasis for physical PURPOSES
therapists and physical therapist assistants. The purpose of Certain physical and cognitive competencies are re-
this paper is to present recommended guidelines for blood quired in order for all health care providers to perform a
pressure measurement by physical therapists and physical blood pressure measurement procedure. Among the physi-
therapist assistants. cal requirements, are the eye/hand/ear coordination to use
the valve mechanism of mercury or aneroid sphygmoma-
SOURCES OF ERROR IN BLOOD PRESSURE nometers, the ability to hear and differentiate the Korotkoff
MEASUREMENT sounds, and the ability to see the meniscus of the mercury
Controlling for error in blood pressure measurement column or the dial of the manometer from 3 feet away.
techniques is important if accurate readings are to be ob-
tained. One common source of inaccurate blood pressure Table 3. Recommended “Ideal” Cuff Sizes for Newborns,
interpretation, particularly among older men and women, Infants, Children, and Adults4,7
is the white coat effect that occurs when blood pressure is
Arm Circumference Cuff Size (cm)
elevated only in the presence of the health care worker tak- (cm)
ing the measurement. White coat effect has been defined
Up to 10 4X8 newborn7
as a “persistently elevated average office blood pressure of
>10 to 15 6 X 12 infant7
greater than 140/90 mm Hg with an average awake ambu-
latory reading of less than 135/85”.12 Arrhythmias and stiff 15 to 22 9 X 18 child7
(poorly compliant) arteries, which frequently occur in el- 22 to 26 12 X 22 smalladult4
derly individuals, contribute to the variability of blood pres- 27 to 34 16 X 30 adult (standard)4
sure measurement. Medications, anxiety, time of day, back- 35 to 44 16 X 36 large adult4
ground noise, room temperature, and stimuli such as food, 45 to 52 16 X 42 adult thigh4
alcohol, caffeine, nicotine, and exercise within 30 minutes
Optimal ratios for arm width and length to circumference are presented
before blood pressure measurement also affect the read- only for the small and standard adult cuff sizes, because the ideal width:
ing. Crossing legs, talking, and doing mental tasks while the circumference ratio is not clinically practical for the large adult and
measurement is being done increases blood pressure.4,8,13 A thigh cuffs (although the ideal length:circumference ratio is presented).
non-exhaustive list of additional common error sources for Modified from Pickering et al4 and National High Blood Pressure Education Program Working
blood pressure measurement is presented in Table 2. Group on High Blood Pressure in Children and Adolescents7

The problem of “miscuffing” constitutes the most fre-

quent error in the measurement of blood pressure.15 The
most recent American Heart Association guidelines spec-
ify that the proper cuff has a bladder length of 80% and a
width of at least 40% of arm circumference.4 The therapist
must determine the proper cuff size by determining the cir-
cumference of the arm at the half-way point between the
olecranon and the acromion processes.4,7,16,17 Although it
is important to use the correct size cuff when measuring
blood pressure, it is generally recognized that the measure-
Standardizing blood pressure measurement and train-
ing techniques is important for physical therapy education
programs and for clinical practice to improve the accura-
cy of blood pressure measurement by physical therapists.
The recommended procedures to be followed in obtaining
baseline or diagnostic blood pressure measurement are dis-
cussed below and summarized in the Appendix. In order
to minimize measurement error, the equipment to be used,
whether aneroid, electronic, or mercury, should be regu-

6 Cardiopulmonary Physical Therapy Journal Vol 22 v No 2 v June 2011

larly inspected and calibrated. Equipment users should be
trained regularly in the proper, standardized technique.4,18-21
Unless otherwise specified, blood pressure measurements
are, by convention, understood to have been obtained from
the upper arm of the patient/client. Although many cli-
nicians believe that blood pressure readings obtained in
either the seated or supine positions are equivalent, such
has not proven to be the case.22 The present consensus
suggests that patients/clients should be seated quietly in a
chair with back support, with both feet flat on the floor for
at least 5 minutes prior to obtaining a measurement.3,4,19
The initial visit blood pressure should be measured in both
arms. According to Pickering et al4 “the patient should be
instructed to relax as much as possible and to not talk dur-
ing the measurement procedure.” Blood pressure should
also be measured in standing for those patients who are
at risk for postural hypotension (eg, elderly, patients with
diabetes, and patients on antihypertensive medications).4
To date, the mercury sphygmomanometer remains
the “gold standard” device for blood pressure measure-
ment.4,19,23 However, because they are being replaced due
to environmental concerns in many practice settings (eg,
having been banned in Veterans Administration Hospi-
tals), there is a role for other types of devices (eg, aneroid
sphygmomanometers and digital electronic pressure trans-
ducers).4,24 There is controversy regarding the accuracy
of blood pressure measurement using automated devices.
Evidence has shown that automated devices tend to un-
derestimate both systolic and diastolic blood pressures in
adults,25 and overestimate both systolic and diastolic pres-
sures in children and adolescents 5 to 17 years of age.26
The blood pressure cuff should be placed on the patient’s
bare arm. If necessary, clothing should be removed, and
the patient/client draped, to adequately expose the arm.
The sleeve should not simply be rolled up in order to gain
access to the arm; it creates a tourniquet effect above the
cuff. When placing the cuff on the arm, the midline of the
inflatable bladder should be positioned over the brachial
artery (the artery coursing between the biceps and triceps
muscles, on the medial aspect of the arm) at the mid-point
of the upper arm. The lower-most edge of the cuff should be
at least 1 inch (2.5 cm) above the antecubital crease so that
the bell (preferred) or the diaphragm of the stethoscope can
be placed over the point of the strongest palpable brachial
artery pulse in the antecubital fossa without encroaching
beneath the cuff.3,4,19 If necessary, the blood pressure can
be measured with the cuff placed on the forearm with aus-
cultation over the radial artery, but this may yield a falsely
high systolic blood pressure.3
Because of the effects of hydrostatic pressure, the posi-
tion of the arm when the blood pressure is measured can
also have a major impact on the pressure observed.16,19 The
magnitude of this effect is 1 to 2 mm Hg for every 2.5 cm
above or below the level of the heart. If the cuff and the up-
per arm are maintained above the level of the right atrium,
the readings obtained will be too low.12,22,27,28 Likewise, if
they are below the level of the heart, the readings will be
too high.12,22,27,28 Thus, when taking the measurement, the
therapist should support the arm so that the cuff is at the
Vol 22 v No 2 v June 2011 Cardiopulmonary Physical Therapy Journal
level of the right atrium with the arm straight and the an-
tecubital fossa “faces upward.” Since muscle contraction
raises blood pressure, care should also be taken to avoid
the patient/client helping to elevate the limb; if available,
pillows or bolsters may also be used to properly position
and support the arm.
In order to avoid over inflation of the cuff, and to ac-
commodate any systolic auscultatory gap, the clinician
should estimate a maximum inflation point by palpating
the radial pulse while incrementally inflating the cuff until
the pulse disappears. The therapist should then wait at least
one minute after deflating the cuff before reinflating the cuff
to 30 mm Hg above the point where the pulse previously
disappeared. Alternatively, one may auscultate the brachi-
al artery while incrementally inflating the cuff to 30 mm
Hg above the point at which the tapping noise (Korotkoff
sounds) disappears. Blood pressure results are significantly
influenced by the rate of cuff deflation--too rapid a rate
leads to marked underestimation of systolic and overesti-
mation of diastolic pressure. Therefore, the recommended
deflation rate is 2 mm Hg per second (or per pulse when the
heart rate is below 60 beats per minute).4,20 Systolic blood
pressure should be recorded as the point at which ausculta-
tory pulsations (Korotkoff phase I) are heard as the cuff is
deflated. The disappearance of the auscultatory pulsations
(Korotkoff phase V) defines the diastolic pressure in adults.
In some circumstances (eg, children, especially young
adolescents, pregnancy, exercise) when sounds are heard
to near zero the Korotkoff phase IV (muffling of sounds) is
used to indicate the diastolic pressure, and the reading at
each of the 3 phases should be recorded (eg, Phase I=120,
Phase IV=60, Phase V=0).12,29-31 Therefore the blood pres-
sure would be recorded as 120/60/0 mm Hg. Pressures
should be read to the nearest 2 mm Hg when using aneroid
or mercury devices.4
The accuracy of blood pressure measurements is of
extreme importance. For example, in a recent review
McAlister and Strauss32 suggested that almost two-thirds
of hypertensive individuals would be denied morbidity
preventing treatment if the diastolic blood pressure were
underestimated by 5 mm Hg; the number of persons diag-
nosed with hypertension would more than double if systol-
ic pressure were over estimated by 5 mm Hg. Therefore, to
strengthen the accuracy of blood pressure measurements, it
is recommended that more than one reading be taken.32,33
Although no clear rationale for a specific number of read-
ings has emerged from the literature, Pickering et al4 rec-
ommend that the average of at least two readings should be
taken at an interval of at least one minute to represent the
patient’s/client’s blood pressure. If the difference between
the first two readings is more than 5 mm Hg, one or two
additional readings should be obtained, and the average of
the multiple readings should be used.
Almost all studies have reported finding differences be-
tween the blood pressures measured in both arms. These
differences seem to arise more frequently when only a
single measurement is taken in each arm, and they are
not attributable to the handedness of the patient/client.34,35
Nevertheless, even when 3 measurements from each arm
7
were analyzed, about 15% of subjects had inter-arm differ-
ences of greater than 10 mm Hg. Therefore, blood pressure
should be checked in both arms at the first examination, at
least, and the arm with the higher pressure should be used
for subsequent monitoring assessments.
As might be anticipated, the guidelines for obtain-
ing baseline/diagnostic blood pressure measurements are
more stringent than those for intra-session monitoring.
Blood pressure measurement in these situations is usually
performed to judge vital signs or assess specific interval
changes in response to activity rather than the presence or
absence of hypertension. And, although they are not diag-
nostic, high readings or abnormal blood pressure responses
(eg, more than a 10 mm Hg increase in systolic pressure per
metabolic equivalent of work) are suggestive of a need for
follow-up.36-38
BLOOD PRESSURE MEASUREMENT IN CHILDREN
Blood pressure should be measured in children under
3 years of age who have any particular conditions warrant-
ing this evaluation such as congenital heart disease, renal
disease, systemic diseases or medications that may cause
hypertension, elevated intracranial pressure, malignancy,
transplantation, or a previous condition requiring inten-
sive care treatment.8 Otherwise, blood pressure should be
measured in children who are at least 3 years old.7,17 As
in adults, the use of Korotkoff sounds via the auscultatory
method is recommended since research has shown that
oscillometric values tend to be less accurate than auscul-
tated values in children.7,39 Although there is some debate
as to which Korotkoff sound should be used to measure
diastolic pressure, especially in the pre-teenage years,40 use
of the Korotkoff phase V (sound disappears) is preferred.7
Korotkoff phase IV (sound muffles) can be used in children
where the Korotkoff sounds are audible until complete or
near-complete cuff deflation.7 It is recommended that prior
to labeling a child’s blood pressure as elevated at least 3
Table 4. Midpoint and 90th Percentile Blood Pressure Levels for Girls and Boys at the 5th and 95th Percentiles of Height7
Age Range of Blood Pressure
*< 90th percentile is
considered normal
1 year old Midpoint of range
90th percentile of range
3 year old Midpoint of range
90th percentile of range
5 year old Midpoint of range
90th percentile of range
10 year old Midpoint of range
90th percentile of range
15 year old Midpoint of range
90th percentile of range
**Once a child is at least 11 years old, BP ≥ 120/80 mm Hg is regarded as prehypertension.
8 Cardiopulmonary Physical Therapy Journal
repeated measures using the auscultatory method are need-
ed.7 If an elevated finding is new and the patient is symp-
tomatic, immediate referral to the physician is imperative.
This is especially important since the majority of children
and adolescents who have hypertension and prehyperten-
sion are undiagnosed.17
Although the actual technique of obtaining a child’s
blood pressure is performed similarly to the adult, a few
tips for accurate blood pressure measurement in the pedi-
atric population should be taken into account:
The usual practice is to use the patient’s right arm for
reliability and assessment when comparing systolic and
diastolic blood pressure measures with the standard values.
This is because of the chance of coarctation of the aorta,
which could result in an inaccurately low reading in the
left arm.7,17
The main difference one should consider when taking
a pediatric patient’s blood pressure is that body size and
age are needed to determine normal values for each child.
Reference tables using a child’s sex, age, and height pro-
vide more exact information.41 In order to determine the
blood pressure range for a child, the height percentile for
age is beneficial. This data can be found at www.cdc.gov/
growthcharts. Table 4 presents blood pressure ranges for
girls and boys by age and height.7 The lower values in the
table correspond to children of that age at the 5th percen-
tile of height, while higher values apply to children at the
95th percentile of height. For example, a midrange blood
pressure for a 5-year-old girl at the 5th percentile of height
would be 89/52 mm Hg; for the same girl, a blood pressure
of 103/66 mm Hg would be interpreted as “pre-hyperten-
sion” since these values fall at the 90th percentile of the
range. Similarly, a 5-year-old girl at the 95th percentile of
height should have a blood pressure no higher than about
109/70. Blood pressure values that fall within the 90-95th
percentile ranges are interpreted as “pre-hypertension” and
values greater than this are interpreted as “hypertension.”
Girls Boys
SBP/DBP, mm Hg SBP/DBP, mm Hg
*the lower numbers correspond *the lower numbers correspond to children at the 5th
to children at the 5th percentile percentile of height
of height *the higher numbers correspond to children at the 95th
*the higher numbers correspond percentile of height
to children at the 95th
percentile of height
83-90/38-42 80-89/34-39
97-103/52-56 94-103/49-54
86-93/47-51 86-95/44-48
100-106/61-65 100-109/59-63
89-96/52-56 90-98/50-55
103-109/66-70 104-112/65-70
98-105/59-62 97-106/58-63
112-118/73-76 111-119/73-78
107-113/64-67 109-117/61-66
**120/78-80 **120/76-80
Vol 22 v No 2 v June 2011
BLOOD PRESSURE MEASUREMENT IN SPECIAL
SITUATIONS
Peripherally Inserted Central Catheters
Blood pressure measures, per expert opinion, should be
avoided in the upper arm in which there is a peripherally
inserted central catheter (PICC) line present.42
Dialysis shunt or fistula
Blood pressure should be taken in the opposite arm
if the patient has a working graft or arteriovenous fistula
needed for dialysis.43 Per expert opinion this is to avoid pos-
sible trauma or clot formation.
Patients with obesity
If the cuff that is available is too small, especially if up-
per arm circumference is > 50 cm, blood pressure can be
measured in the forearm.4
Forearm measurement of blood pressure
In cases where neither upper arm can be used for a
blood pressure measurement, an alternative site would be
the forearm. The systolic blood pressure measurement can
be estimated by placing the cuff on the forearm with the
forearm supported at the level of the heart and palpating
for the appearance of the radial pulse as the cuff is deflated.
Auscultation of Korotkoff sounds over the radial artery or
using a Doppler also can be done. Systolic blood pressure
tends to be higher in the forearm and can differ from upper
arm measurements by up to 20 mm Hg.44 Validation of the
accuracy of forearm measurement techniques has not been
achieved.4 Therefore forearm and upper arm blood pres-
sure measurements are not interchangeable and should be
labeled in any documentation to clearly indicate the mea-
surement site.
Radial artery recently used for CABG
Although it is expert opinion, if the radial artery is used
as a graft during coronary artery bypass graft surgery, it is
best to not perform blood pressure measurements in that
arm for at least the initial days after surgery.45
Cardiac dysrhythmias
If the heart rhythm is chaotic (eg, atrial fibrillation),
blood pressure measures will fluctuate as the heart rate
changes. Therefore the recommendation is to take the aver-
age of more than one measurement. For slow heart rates,
the speed of deflation of the cuff also needs to be reduced
for a more precise appraisal of blood pressure.4
Elderly
It is recommended by Pickering et al4 that standing
blood pressure measurements in the elderly, especially
for those with diabetes, be assessed to rule out possible
postural hypotension. This is defined by a systolic pressure
drop by more than 20 mm Hg or a diastolic pressure drop
by more than 10 mm Hg while the patient stands for up to
3 minutes. The patient may or may not have complaints
such as lightheadedness, dizziness, and blurred vision or
the therapist may note cognitive changes.4
Vol 22 v No 2 v June 2011 Cardiopulmonary Physical Therapy Journal
Lymphedema
Blood pressure should be measured in the contralat-
eral arm in a patient who has had a unilateral mastectomy.
There is controversy regarding whether the measurement of
blood pressure damages the lymphatics and increases the
likelihood of lymphedema.46 There is no data to support
the theory that the tourniquet effect of the blood pressure
cuff damages the lymphatic system and causes or increases
edema. Evidence suggests that there is less risk of lymph-
edema occurring with blood pressure measurement when
the axillary nodes have not been dissected compared to
when axillary node dissection has been performed.16
Pregnancy
Blood pressure is important to monitor in pregnant
women because hypertension is the most common medi-
cal complication in pregnancy and occurs in up to 12% of
this population.4 Accurate monitoring of blood pressure
during pregnancy is an important aspect of good quality
prenatal care. Blood pressure tends to decrease early in
gestation and frequently is 10 mm Hg below pre-pregnancy
levels. The mean blood pressure in the second trimester is
105/60 mm Hg. The decline in blood pressure is due to pe-
ripheral vasodilatation the causes of which are not clearly
understood.47
Other considerations
For patients with sounds not audible per auscultation
(eg, those with weak Korotkoff sounds), a Doppler probe
can be used over the brachial artery to determine the pa-
tient’s systolic pressure. The therapist also can palpate the
return of the radial pulse as the cuff deflates for an es-
timate of the systolic blood pressure and document the
measurement as systolic blood pressure per palpation (eg,
100 mm Hg per palp). In both of these cases, a diastolic
pressure cannot be obtained. If the upper arm is unable to
be used for a blood pressure measurement, the cuff can
be placed on the forearm with the examiner auscultat-
ing over the radial artery. As stated earlier, accuracy of
forearm blood pressure measurement has not been vali-
dated.4 If the leg is the only alternative for blood pressure
measurement, the cuff can be placed on the thigh. In this
case, the popliteal artery is used for auscultation. Systolic
blood pressure measured in the leg (in the seated position)
in normal subjects is typically 10% to 20% higher than
systolic blood pressure measured in the brachial artery.16
Leg systolic blood pressure more than 10% lower than
brachial artery systolic blood pressure may indicate pe-
ripheral arterial disease.16
DOCUMENTATION
It is important to document on which side the blood
pressure was measured and state if the forearm was used.
In order to achieve accuracy for repeated measures, it is
critical for therapists to be consistent in their methodology
of blood pressure measurement. Therefore it is imperative
to document when the method of blood pressure measure-
ment deviated from the standard protocol.
9
CONCLUSION
Physical therapists and physical therapist assistants are
trained in the techniques of blood pressure measurement
as part of basic professional education. However, they can-
not really claim to be adequately using this skill in the best
interests of patients in our normal clinical practices unless
it is properly and appropriately performed.48
If physical therapists wish to play an important role as
primary health care providers, we must, as suggested by
Frese and colleagues,48 be more proactive in our assess-
ments of blood pressure and the other vital signs. Only
then, will they be able to optimally contribute to the iden-
tification and management of blood pressure problems in
the patients they serve while also lending the greatest as-
sistance to other health professionals.
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(references continued on page 12)
Vol 22 v No 2 v June 2011
Appendix. Recommended Technique for Measuring Blood Pressure3,4

i. Measurements should be taken with a sphygmomanometer known to be accurate. A recently calibrated

aneroid or a validated and recently calibrated electronic device can be used. Aneroid devices or mercury
columns need to be clearly visible at eye level.

ii. Choose a cuff with an appropriate bladder size matched to the size of the arm. For measurements taken
by auscultation, bladder width should be close to 40% of arm circumference and bladder length should
cover 80% to 100% of arm circumference. When using an automated device, select the cuff size as
recommended by its manufacturer.

iii. Place the cuff so that the lower edge is at least 1 in (2.5 cm) above the elbow crease and the bladder is
centered over the brachial artery. The patient/client should be resting comfortably for 5 minutes in the
seated position with back support. The arm should be bare and supported with the antecubital fossa
at heart level because a lower position will result in erroneously higher systolic and diastolic blood
pressure measurements. There should be no talking, and patients’ legs should not be crossed. At least
two measurements should be taken in the same arm with the patient in the same position, and the mean
should be recorded. Blood pressure also should be assessed after two minutes of standing (with arm
supported) and at times when patients report symptoms suggestive of postural hypotension. Supine blood
pressure measurements may also be helpful in the assessment of elderly and diabetic patients.

iv. Increase the pressure rapidly to 30 mm Hg above the level at which the radial pulse is extinguished (to
exclude the possibility of a systolic auscultatory gap).

v. Place the bell or diaphragm of the stethoscope gently and steadily over the brachial artery.

vi. Open the control valve so that the rate of deflation of the cuff is approximately 2 mm Hg per heart beat (or
per second if HR is less than 60 bpm). A cuff deflation rate of 2 mm Hg per beat is necessary for accurate
systolic and diastolic estimation.

vii. Read the systolic level (the first appearance of a clear tapping sound [phase I Korotkoff]) and the diastolic
level (the point at which the sounds disappear [phase V Korotkoff]). Continue to auscultate at least 10
mm Hg below phase V to exclude a diastolic auscultatory gap. Record the blood pressure to the closest 2
mm Hg on the manometer (or 1 mm Hg on electronic devices), as well as the arm used and whether the
patient was supine, sitting, or standing. Avoid digit preference by not rounding up or down. Record the
heart rate. The seated blood pressure is used to determine and monitor treatment decisions. The standing
blood pressure is used to examine for postural hypotension, if present, which may modify the treatment.

viii. If Korotkoff sounds persist as the level approaches 0 mm Hg, then the point of muffling of the sound is used
(phase IV) to indicate the diastolic pressure.

ix. In the case of arrhythmia, additional readings may be required to estimate the average systolic and diastolic
pressure. Isolated extra beats should be ignored. Note the rhythm and pulse rate.

x. To avoid venous congestion, it is recommended that at least 1 minute should elapse between readings.
Leaving the cuff partially inflated for too long will fill the venous system and make the sounds difficult to
hear.

xi. Blood pressure should be taken in both arms on, at least, the first visit; if one arm has a consistently higher
pressure, then that arm should be clearly noted and subsequently used for blood pressure measurement
and interpretation.

Vol 22 v No 2 v June 2011 Cardiopulmonary Physical Therapy Journal 11

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